Apparatus and method for treating a patient using vibration stimuli, tactile stimuli and/or thermal stimuli

ABSTRACT

The invention relates to a device ( 100 ) for treating a patient with vibration and/or tactile and/or thermal stimuli ( 20 ), said device ( 100 ) containing a first and second stimulating unit ( 11, 12 ) for generating first and second stimuli respectively. The stimuli are vibration and/or tactile and/or thermal stimuli, and each of the stimuli is repeated on average at a frequency of 1 to 60 Hz. The stimuli are generated at at least partly different times.

The invention relates to an apparatus and to a method for treating a patient using vibration stimuli and/or tactile stimuli and/or thermal stimuli.

The invention in particular relates to a stimulation apparatus and to a stimulation method for treating diseases in which there is increased neuronal synchronization. In particular diseases of the brain can be treated using the invention such as locomotor disorders, Parkinson's disease, essential tremor, dystonia, migraine, tension headache, spasticity, functional disorders after stroke, neuropathic pain, chronic pain, neuralgias, post-amputation pain, tremor and other functional disorders following brain trauma. Gastrointestinal diseases such as irritable bowel syndrome can, however, also be treated. In this respect, painful cramps and inefficient bowel motility can be unlearned. The treatment using the apparatus in accordance with the invention can also have an antispasmodic and pain-relieving effect in cases of ulcerative colitis and of Crohn's disease. Furthermore, asthma bronchiale, cardiac ischemia and peripheral arterial occlusive disease can be treated using the apparatus in accordance with the invention.

The only therapies—if any—for treating the aforesaid diseases are pharmacological or stereotactic therapies. The effectiveness of pharmacological therapies is typically limited in time. The stereotactic treatment harbors relevant risks such as the risk of arterial bleeding on the implantation of brain pacemakers.

Against this background, an apparatus in accordance with claim 1, a use of the apparatus claimed in claim in accordance with claim 12, further apparatus in accordance with claims 13 and 15 and a method in accordance with claim 17 are set forth. Advantageous further developments and embodiments of the invention are named in the dependent claims.

The invention will be described in more detail in an exemplary manner in the following with reference to an embodiment and to the drawings. There are shown in these:

FIG. 1 a schematic representation of an apparatus 100 for generating vibration stimuli, tactile stimuli and/or thermal stimuli in accordance with an embodiment;

FIG. 2 a schematic representation of a stimulation method carried out using the apparatus 100;

FIGS. 3A to 3D schematic representations of vibration stimuli;

FIG. 4 a schematic representation of a tactile stimulus;

FIGS. 5A to 5C schematic representations of thermal stimuli;

FIG. 6 a schematic representation of the apparatus 100 during its intended use;

FIGS. 7 to 9 schematic representations of stimulation methods carried out using the apparatus 100;

FIG. 10 a schematic representation of an apparatus 200 for generating vibration stimuli, tactile stimuli and/or thermal stimuli in accordance with a further embodiment;

FIGS. 11A to 13C schematic representations of stimulation units for generating vibration stimuli and/or tactile stimuli;

FIGS. 14A to 15C schematic representations of stimulation units for generating thermal stimuli;

FIGS. 16 and 17 schematic representations of stimulation methods; and

FIGS. 18 to 19C schematic representations of an apparatus 300 for generating vibration stimuli, tactile stimuli and/or thermal stimuli in accordance with a further embodiment.

An apparatus 100 for the non-invasive treatment of a patient using vibration stimuli, tactile stimuli and/or thermal stimuli is shown schematically in FIG. 1. The apparatus 100 in the embodiment shown in FIG. 1 comprises a first stimulation unit 11 for generating first stimuli, a second stimulation unit 12 for generating second stimuli, a third stimulation unit 13 for generating third stimuli and a fourth stimulation unit 14 for generating fourth stimuli. The embodiment shown in FIG. 1 is only to be understood in an exemplary manner. Alternatively to this embodiment, the apparatus 100 can include any desired number N (N=2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, . . . ) of stimulation units. The apparatus 100 can furthermore have a control unit 10 which is connected to the stimulation units 11 to 14 via suitable connection lines or via radio and which controls the generation of the stimuli. The control unit 10 can also be integrated in one or more or all the stimulation units 11 to 14.

The stimulation units 11 to 14 can each generate one or more stimuli from the group of vibration stimuli, tactile stimuli and thermal stimuli. The stimulation units 11 to 14 are designed such that they can be placed on the skin of the patient. Depending on the disease and/or on the effected parts of the body, the stimulation units 11 to 14 are secured on the skin of the patient in a suitable arrangement, for example to the arm, to the leg, to the hand and/or to the foot of the patient. Vibration stimulation, tactile stimulation and thermal stimulation can each be administered on the skin either individually or in combination depending on the symptoms.

The majority of stimulation units 11 to 14 allow different receptive areas of the skin to be stimulated with temporal and spatial coordination via the individual stimulation units 11 to 14. The stimulation units 11 to 14 can be arranged on the skin of the patient such that the stimuli applied to the skin tissue are forwarded via nerve conductors to different target regions which e.g. lie in the spinal cord and/or in the brain. Consequently, different target regions in the spinal cord and/or in the brain can be stimulated with possibly different and/or time-offset stimuli by means of the apparatus 100 during the same stimulation time period.

A stimulation method which can be carried out using the apparatus 100 is shown schematically in FIG. 2. The stimuli 20 applied via the stimulation units 11 to 14 are shown over the time t in FIG. 2.

In the method shown in FIG. 2, each of the stimulation units 11 to 14 applies the stimulus 20 periodically to the respective receptive area of the skin on which the stimulation unit 11 to 14 is attached. The frequency f_(stim)=1/T_(stim) (T_(stim)=period duration) at which the stimuli 20 generated by each of the stimulation units 11 to 14 are repeated can lie in the range from 1 to 60 Hz and in particular in the range from 30 to 60 Hz or in the range from 1 to 30 Hz or in the range from 1 to 20 Hz or in the range from 5 to 20 Hz, but can also adopt lower or higher values. The duration D_(stim) of an individual stimulus 20 can in particular depend on the type of the stimulus. The ordinate shown in FIG. 2 likewise depends on the type of stimuli 20. With a vibration stimulus or a tactile stimulus, for example, the deflection 1 of a stimulation element can be entered over the time t; with a thermal stimulus a temperature T can be shown. The stimuli 20 applied via the different stimulation units 11 to 14 can be identical or different.

Different embodiments of individual vibration stimuli 20 are shown un FIGS. 3A, 3B, 3C and 3D. The deflection l of a stimulation element is entered against the time t there. The stimulation element is deflected from its position of rest at the time t₁ in FIG. 3A and is pressed into the skin of the patient. The position of the skin surface is shown by a dashed line 21. Once the stimulation element has come into contact with the skin, a periodic vibration stimulus is applied at a frequency f_(vib)=1 T_(vib) in the range from 30 to 300 Hz (T_(vib)=period duration of the vibration stimulus). At a frequency f_(vib) of 300 Hz, the stimulation element can exert a force of approximately 2 N. The duration D_(stim) of the vibration stimulus 20 can lie in the range from 10 to 500 ms. The stimulation duration D_(stim) in particular lies in the range from

$\begin{matrix} {{0 < D_{stim} < \frac{T_{stim}}{N}},} & (1) \end{matrix}$

where N is the number of stimulation units. A range of 10 to 250 ms e.g. results for the stimulation duration D_(stim) for T_(stim)=1 Hz and N=4. Time-overlapping stimuli can, however, also be used.

At the time t₂, the stimulation element is again moved to its position of rest where it has no contact with the skin. As shown in FIG. 3A, the vibration stimulus 20 can be a rectangular or sinusoidal stimulus, but it can also have different forms. The deflection l₁ shown in FIG. 3A for pressing the stimulation element into the skin can lie in the range from 0.5 to 3 mm. The deflection l₂ of the stimulation element during the vibration can amount to between 0.1 and 0.5 mm.

A variation of the vibration stimulus 20 shown in FIG. 3A is shown in FIG. 3B. In the embodiment shown in FIG. 3B, the stimulation element is always in contact with the skin of the patient. A vibration stimulus 20 as described above is applied during the stimulation period D_(stim).

A further variation of the vibration stimulus 20 is shown in FIG. 3C. Unlike the vibration stimulus 20 of FIG. 3A, the stimulation element is already withdrawn during the stimulation period D_(stim) so that the vibrations press less far into the skin as the time duration increases and the stimulation element is finally completely released from the skin. The withdrawal of the stimulation element can, for example, take place along a linear or non-linear curve 22, e.g. an exponential curve, on which the vibrations f_(vib) of the stimulation element are superimposed. In the example shown in FIG. 3C, the falling flank of each pulse extends down to the curve 22. The adjoining pulse has a fixedly preset height l₂, i.e. the rising flank of each pulse has the height l₂.

A variation of the vibration stimulus 20 of FIG. 3 c is shown in FIG. 3D. The curve 22 there does not return to the zero line (l=0), but has a fixedly preset offset ΔL from the zero line.

An embodiment of a tactile stimulus 20 is shown in FIG. 4. The stimulation element is pressed into the skin of the patent at the time t₁, remains there for the stimulation duration D_(stim) and is withdrawn again at the time t₂. The stimulation duration D_(stim) with a tactile stimulation 20 lies in the range from 10 to 500 ms. The stimulation duration D_(stim) in particular lies in the range given above in (1); time-overlapping stimuli can, however, also be used.

Different embodiments of individual thermal stimuli 20 are shown in FIGS. 5A, 5B and 5C. In the embodiments shown in FIGS. 5A and 5B, a stimulation element is heated or cooled to a temperature T_(temp). As is shown in FIG. 5B, the temperature T_(temp) can only be generated just before the application of the thermal stimulus 20. In this case, the stimulation element has a temperature T₀ during the stimulation pauses which corresponds e.g. to the room temperature. Alternatively, the stimulation element can be maintained at a constant temperature T_(temp).

In the embodiment in accordance with FIG. 5A, the heated or cooled stimulation element is applied to the skin of the patient at the time t₁ and remains there for the total stimulation duration D_(stim). In contrast to this, in the embodiment in accordance with FIG. 5B, the stimulation element is applied periodically to the skin with a frequency f_(thermo) during the stimulation duration D_(stim) and is removed again. The frequency f_(thermo)=1/T_(thermo) can lie in the range from 1 to 10 Hz (T_(thermo)=period duration of the thermal stimulus).

The thermal stimulus 20 shown in FIG. 5C substantially corresponds to the thermal stimulus 20 of FIG. 5B. The difference is that the thermal stimulus 20 of FIG. 5C is generated contactlessly. Here, the stimulation temperature T_(temp) is generated by electromagnetic radiation, for example by infrared light. Furthermore, the electromagnetic radiation is periodically varied with the frequency f_(thermo)=1/T_(thermo) (e.g. by switching an infrared radiator on and off).

With thermal stimuli, the stimulation duration D_(stim) lies in the range from 10 to 500 ms. The stimulation duration D_(stim) in particular lies in the range given above in (1); time-overlapping stimuli can, however, also be used. The temperature T_(temp) can be from 22 to 42° C. The temperature T₀ is as a rule the body temperature of the patient. The frequency f_(thermo) can lie between 1 and 10 Hz, but can also lie outside this range.

It is also conceivable that an individual stimulus 20 includes a plurality of types of stimulus. For example, the vibration stimulus 20 shown in FIG. 3A can simultaneously be a thermal stimulus provided that the stimulation element exerting the stimulus is correspondingly heated or cooled. The vibration stimulus 20 of FIG. 3A is furthermore simultaneously a tactile stimulus (tactile receptors are activated by the impact of the stimulation element on the skin).

The apparatus 100 can in particular be used for treating diseases in which an increased neuronal synchronization is present. In particular diseases of the brain can be treated using the apparatus 100 such as locomotor disorders, Parkinson's disease, essential tremor, dystonia, migraine, tension headache, spasticity, functional disorders after stroke, neuropathic pain, chronic pain, neuralgias, post-amputation pain, tremor and other functional disorders following brain trauma. Gastrointestinal diseases such as irritable bowel syndrome can, however, also be treated. Furthermore ulcerative colitis, Crohn's disease, asthma bronchiale, cardiac ischemia and peripheral arterial occlusive disease can be treated using the apparatus 100.

The aforesaid diseases can be caused by a disorder of the bioelectric communication of neural assemblies which are connected in specific circuits. In this respect, a neuronal population continuously generates pathological neuronal activity and possibly a pathological connectivity associated therewith (network structure). In this respect, a large number of neurons synchronously form action potentials, i.e. the participating neurons fire excessively synchronously. In addition, there is the fact that the pathological neuronal population has an oscillatory neuronal activity, i.e. the neurons fire rhythmically. In the case of neurological or psychiatric diseases, the mean frequency of the pathological rhythmic activity of the affected neural assemblies lies approximately in the range from 1 to 30 Hz, but can also be outside this range. In healthy people, the neurons fire qualitatively differently, however, e.g. in an uncorrelated manner.

The stimuli applied by the stimulation units 11 to 14 are received by receptors disposed in or beneath the skin and are forwarded to the nervous system. These receptors include, for example, Merkel cells, Ruffini corpuscles, Meissner's corpuscles and hair follicle receptors which in particular act as receptors for the tactile stimuli 20. The vibration stimuli 20 are predominantly directed to proprioception. The vibration stimuli 20 can be received by receptors disposed in the skin, in the muscles, in the subcutaneous tissue and/or in the sinews of the patient. Pacini's corpuscles, which communicate vibration perceptions and accelerations, can be named as examples for the vibration stimuli. The thermal stimuli are received by the thermoreceptors of the skin. They are warm receptors (also called heat receptors, warm sensors or heat sensors) and cold sensors (also called cold receptors). The cold sensors are more superficial in the skin of people; the heat receptors somewhat lower.

The stimuli 20 generated by the stimulation elements 11 to 14 are designed such that they effect a reset of the phase of neuronal activity of the stimulated neurons in a neuronal population when they are received by the corresponding receptors and are conducted via the nerve conductors to the neuronal population in the brain or spinal cord with a pathologically synchronous and oscillatory activity. The phase of stimulated neurons is set to a specific phase value, e.g. to 0°, independently of the current phase value by the reset. The phase of the neuronal activity of the pathological neuronal population is thus controlled by means of a direct stimulation.

It is furthermore possible on the basis of the plurality of stimulation elements to stimulate the pathological neuronal populations at different points. The stimuli 20 applied to different points of the skin are namely forwarded to different points in the brain or spinal cord. This makes it possible to reset the phase of neuronal activity of the pathological neuronal population at the different stimulation points at different times. As a result, the pathological neuronal population whose neurons were previously active synchronously and at the same frequency and phase are split into a plurality of subpopulations. The neurons are still synchronous and also still fire at the same pathological frequency within a subpopulation, but each of the subpopulations has that phase with respect to its neuronal activity which is imposed on it by the stimulus.

Due to the pathological interaction between the neurons, the state with at least two subpopulations generated by the stimulation is unstable and the total neuronal population fast approaches a state of complete desynchronization in which the neurons fire without correlation. The desired state i.e. the complete desynchronization is thus not immediately present after the application of the stimuli 20, but is usually adopted within a few periods or even in less than one period of pathological activity.

With the above-described type of stimulation, the ultimately desired desynchronization is only made possible by the pathologically increased interaction between the neurons. In this respect, a self-organization process is utilized which is responsible for the pathological synchronization. The same process has the effect that a division of a total population into subpopulations with different phases is followed by a desynchronization. In contrast to this, no effective desynchronization would take place without pathologically increased interaction of the neurons.

Furthermore, a reorganization of the connectivity of the disturbed neuronal networks can be achieved by the stimulation using the apparatus 100 so that long-continuing therapeutic effects can be brought about.

The stimulation of a plurality of subpopulations of a pathologically active neuronal population 30 using the apparatus 100 is shown schematically in FIG. 6. The respective receptors are stimulated at different points of the skin 15 by vibration stimuli 20 and/or tactile stimuli 20 and/or thermal stimulation 20 via the stimulation units 11 to 14. The stimuli 20 applied by the stimulation units 11, 12, 13 and 14 are forwarded to different subpopulations 31, 32, 33 and 34 of the neuronal populations 30 (stimuli from stimulation unit 11 to subpopulation 31, stimuli from stimulation unit 12 to subpopulation 32, stimuli from stimulation unit 13 to subpopulation 33 and stimuli from stimulation unit 14 to subpopulation 34) and reset the phases of these subpopulations at respective different points in time, whereby a desynchronization of the total neuronal population 30 is achieved.

The achieved stimulation of specific regions of the brain or of the spinal cord is make possible by the somatotopic association of body regions with these regions. The stimulation units 11 to 14 can be applied, for example, to the foot, lower leg and thigh or to the hand, the lower arm and upper arm of the patient. Different neurons are stimulated by the stimuli applied to the respective points due to the somatotopic structure of the neural pathways. The somatotopic association of skin points with regions of the brain is described, for example, in A. Benninghoff et al.: “Lehrbuch der Anatomie des Menschen. Dargestellt unter Bevorzugung funktioneller Zusammenhänge. 3. Bd. Nervensystem, Haut und Sinnesorgane”, [Textbook of Human Anatomy. Presented With Emphasis on Functional Relationships. 3rd Vol., Nervous System, Skin and Sensory Organs”], Urban und Schwarzenberg, Munich 1964.

Different procedures can be followed to achieve a desynchronization of the total neuronal population 30 by a time-offset reset of the phases of the subpopulations 31 to 34 of the pathologically synchronous neuronal population 30. For example, the stimuli 20 which effect a reset of the phase of neurons can be output to the respective receptive fields of the skin offset in time via the different stimulation units 11 to 14. Furthermore, the stimuli can e.g. be applied offset in phase or with different polarities so that they also lead as a result to a time-offset reset of the phases of the different subpopulations 31 to 34.

A stimulation method suitable for the above-described purposes is shown schematically in FIG. 7. The stimuli 20 applied via the stimulation units 11 to 14 are shown beneath one another over the time t in FIG. 7. The vibration stimuli, tactile stimuli and thermal stimuli shown in FIGS. 3A to 5C can be used as stimuli 20, for example. The diagram shown in FIG. 7 is divided into periodically repeating first time periods of the length T_(stim). The frequency f_(stim)=1/T_(stim) at which the first time periods of the length T_(stim) are repeated can lie in the range from 1 to 60 Hz and in particular in the range from 30 to 60 Hz or in the range from 1 to 30 Hz or in the range from 1 to 20 Hz or in the range from 5 to 20 Hz, but can also have lower or higher values.

The first time periods of the length T_(stim) are further more divided into two time periods of the length T_(stim)/4. On a stimulation via N stimulation units, the first time periods could be divided into N second time periods of the length T_(stim)/N.

In accordance with an embodiment, each of the stimulation units 11 to 14 generates no more than one stimulus 20 within a first time period. Stimuli 20 from different stimulation units 11 to 14 can be generated in second time periods following one another.

In the embodiment shown in FIG. 7, each of the stimulation units 11 to 14 applies a stimulus 20 strictly periodically at the frequency f_(stim). The administration of the stimuli 20 via different stimulation units 11 to 14 takes place with a time delay between the individual stimulation units 11 to 14 by T_(stim)/4.

In the case of N stimulation time units, the time delay between two respective mutually following stimuli 20 can lie, for example, in the range of an Nth of the period 1/f_(stim), i.e. 1/(N×f_(stim))=T_(stim)/N, i.e. in particular the time T_(stim)/N elapses between the start times of two mutually following stimuli 20.

The frequency f_(stim) can lie, for example, in the range of the mean frequency of the pathologically rhythmic activity of the target network. With diseases in which an increased neuronal synchronization is present, the mean frequency typically lies in the range from 1 to 30 Hz, but can also lie outside this range. It must be noted in this respect that the frequency at which the affected neurons fire synchronously is usually not constant, but can rather certainly have variations and furthermore shows individual deviations in each patient.

Deviations from the strictly periodic stimulation patterns shown in FIG. 7 can take place in different manners. For example, the time delay T_(stim) between mutually following stimuli 20 generated by the same stimulation unit cannot always be of equal magnitude, but can rather vary in the range of ±10% or ±5% or ±3% around T_(stim). Furthermore, the time interval between two mutually following stimuli 20 generated by different stimulation units can also vary in the range of ±10% or ±5% or ±3% around T_(stim)/N. Provision can by all means be made that the time intervals between the individual stimuli 20 are selected as different. Furthermore, the delay times can also be varied during the treatment of a patient. The delay times can also be adjusted with reference to the physiological signal transit times.

Furthermore, pauses can be provided during the application of the stimuli 20 during which no stimulation occurs. Such a pause is shown by way of example in FIG. 8. The pauses can be selected to be of any desired length and can in particular amount to a whole-number multiple of the period T_(stim). Furthermore, the pauses can also be observed after any desired number of stimulations. E.g. a stimulation can be carried out during n mutually following periods of the length T_(stim) and subsequently a pause can be observed during m periods of the length T_(stim) without stimulation, where n and m are small whole numbers, e.g. in the range from 1 to 10. This scheme can either be continued or modified periodically or stochastically and/or deterministically or in mixed stochastic/deterministic form.

A further possibility to deviate from the strictly periodic stimulation pattern shown in FIG. 7 comprises varying the time sequence of the individual stimuli 20 stochastically or deterministically or in mixed stochastic/deterministic form.

Furthermore, the order in which the stimulation units 11 to 14 apply the stimuli 20 can be varied per period T_(stim) (or also in other time steps), as is shown by way of example in FIG. 9. This randomization can take place stochastically or deterministically or in a mixed stochastic/deterministic manner.

The randomization shown in FIG. 9 can be combined with the stimulation form shown in FIG. 8. For example, a repeat randomization can be carried out in each of the n mutually following stimulation time periods of the length T_(stim) or a randomization takes place after each pause of the lengths m×T_(stim) and the order in which the stimulation units 11 to 14 apply the stimuli 20 remains constant within the n following stimulation time periods.

Furthermore, only a specific number of stimulation units 11 to 14 can be used for the stimulation per period T_(stim) (or in another time interval) and the stimulation units participating in the stimulation can be varied in each time interval. This variation can also take place stochastically or deterministically or in a mixed stochastic/deterministic manner.

It is conceivable that the stimulation is started by the patient, for example by a telemetric activation. In this case, the patient can e.g. activate the stimulation for a predetermined time period of e.g. 60 minutes by means of an external transmitter or the patient can start and end the stimulation independently.

The apparatus 100 can be operated, for example, in a so-called open loop mode in which the control unit 10 controls the stimulation units 11 to 14 such that they generate predefined stimuli 20 which are output to the skin tissue. Furthermore, the apparatus 100 can also be further developed into an apparatus 200 shown in FIG. 10 which represents a so-called closed-loop system. The apparatus 200 additionally includes a measuring unit 16 which provides one or more measured signal taken at the patient and forwards them to the control unit 10. Provision can be made that the control unit 10 controls the stimulation units 11 to 14 using the measured signals taken by the measuring unit 16.

The measuring unit 16 can be non-invasive sensors such as electroencephalography (EEG) electrodes, magnetoencephalography (MEG) sensors, accelerometers, electromyography (EMG) electrodes and sensors for determining blood pressure, respiration or electric resistance of the skin. The measuring unit 16 can furthermore be implanted in the body of the patient in the form of one or more sensors. Deep-brain electrodes, subdural or epidural brain electrodes, subcutaneous EEG electrodes and subdural or epidural spinal cord electrodes can serve as invasive sensors, for example. Furthermore, electrodes to be fastened to peripheral nerves can be used as sensors. The neuronal activity in the stimulated target area, i.e. e.g. the neuronal activity of the neuronal population 30 shown schematically in FIG. 6 or an area associated therewith can in particular be measured by means of the measuring unit 16.

Different embodiments are conceivable with respect to the cooperation of the control unit 10 with the measuring unit 16. A demand activated stimulation can be carried out by the control unit 10, for example. For this purpose, the control unit 10 detects the presence and/or the characteristic of one or more pathological features using the measured signals taken by the measuring unit 16. The amplitude or the amount of the neuronal activity can, for example, be measured and compared with a predefined threshold value. The control unit 10 can be designed so that a stimulation is started as soon as the predefined threshold value is exceeded. Alternatively to the controlling of the times of the stimulation using the measured signals taken by the measuring unit 16 or in addition thereto, the strength of the stimuli can be set by the control unit 10 using the characterization of the pathological features. E.g. one or more threshold values can be predefined and, on an exceeding of the amplitude or of the amount of the measured signals above a specific threshold, the control unit 10 sets a specific strength of the stimuli 20, e.g. a specific frequency f_(vib) or impression depth l₂ in the case of vibration stimuli.

Furthermore, provision can be made that the measured signals taken by the measuring unit 16 are used as stimuli 20 directly or, optionally, after one or more processing steps, and are fed by the control unit 1 into one or more of the stimulation units 11 to 14. For example, the measured signals can be amplified and processed, optionally after mathematical offsetting (e.g. after mixing the measured signals) with a time delay and linear and/or non-linear offset steps and combinations and can be fed into at least one of the stimulation unit 11 to 14. The offset mode is selected in this respect so that the pathological neuronal activity is countered and the stimulation signal likewise disappears or is at least considerably reduced in its strength as the pathological neuronal activity reduces. The (possibly forwarded) measured signals can, for example, be applied analogously to the stimulation process in accordance with FIG. 7 with a time delay of T_(stim)/4 via the individual stimulation units 11 to 14.

This type of stimulation in which the measured signals taken at the patient are fed back into the body of the patient for the dresynchronization of a neuronal population could generally also be carried out using only one single stimulation unit; however, any desired larger number of stimulation units can also be provided.

The measured signals can, for example be amplified for generating the stimuli 20 and can be used, optionally after mathematical offsetting (e.g. after mixing the measured signals) with a time delay and linear and/or non-linear offset steps, for the electric control of the stimulation units which then convert the measured signals into vibration stimuli, tactile stimuli or thermal stimuli. The offset mode can in this respect be selected so that the pathological neuronal activity is countered and the applied stimulus likewise disappears or is at least considerably reduced in its strength as the neuronal activity decreases.

In the following, linear and non-linear processing steps will be described with which measured signals acquired with the aid of the measuring unit 16 can be processed before they are used for controlling the stimulation units. On a non-linear processing of the measured signals, the phase of the neuronal activity in the respective stimulated subpopulations is not reset, but rather the synchronization in the pathologically active neuronal population is suppressed in that the saturation process of the synchronization is influenced.

On a linear processing of a measured signal acquired by the measuring unit 16, the measured signal can, for example, be filtered and/or amplified and/or acted on by a time delay before the signal processed in this manner is fed into the stimulation unit and is converted into a vibration stimulus and/or tactile stimulus and/or thermal stimulus. It is assumed as an example that the measured signal had been taken by means of an EEG electrode and represents the pathological activity in the target area. Accordingly, the measured signal is a sine oscillation with a frequency in the range from 1 to 30 Hz. It is furthermore assumed by way of example that the measured signal has a frequency of 5 Hz. The measured signal can be filtered by means of a bandpass filter having a transmission range in the range of 5 Hz and can be amplified by means of an amplifier so that it has a level suitable for the control of the stimulation unit. Subsequently, the amplified sine oscillation thus obtained is used for controlling the stimulation unit. In the case of a stimulation unit for applying vibration stimuli or tactile stimuli, the stimulation element then carries out a sinusoidal movement at a frequency of 5 Hz.

Provided that a number N of stimulation units is used for the stimulation, the measured signal can be acted on by the time delays T_(stim)/N shown in FIG. 7 before it is fed into the corresponding stimulation units.

In the following, it will be explained with reference to an example how a measured signal acquired by the measuring unit 16 can be subjected to a non-linear processing before it is used as a stimulation stimulus. Exactly as in the linear processing, the measured signal can also be filtered and/or amplified and/or acted on by a time delay here.

The starting point is an equation for the stimulation stimulus S(t):

S(t)=K· Z ²(t)· Z *(t−τ  (2)

In equation (2), K is an amplification fact which can be selected suitably and Z(t) is a mean state variable of the measured signal. Z(t) is a complex variable and can be represented as follows:

Z (t)=X(t)+iY(t),  (3)

where X(t) can e.g. correspond to the neurological measured signal and i is the imaginary unit. Since the observed frequencies lie in the range from 10 Hz=1/100 ms=1/T_(α), the imaginary part Y(t) can be approximated by (X(t−τ_(α)), where τ_(α)=T_(α)/4 applies, for example. There thus results:

S(t)=K·[X(t)+iX(t−τ _(α))]² ·[X(t−τ)−iX(t−τ−τ _(α))]  (4)

Equation (4) can be transformed as follows:

$\begin{matrix} {{S(t)} = {K \cdot \left\lbrack {{{X(t)}^{2} \cdot {X\left( {t - \tau} \right)}} + {i\; 2{{X(t)} \cdot {X\left( {t - \tau_{\alpha}} \right)} \cdot {X\left( {t - \tau} \right)}}} - {{X\left( {t - \tau_{\alpha}} \right)} \cdot {X\left( {t - \tau} \right)}} - {i\; {{X\left( {t - \tau - \tau_{\alpha}} \right)} \cdot {X(t)}^{2}}} + {2{{X(t)} \cdot {X\left( {t - \tau_{\alpha}} \right)} \cdot {X\left( {t - \tau - \tau_{\alpha}} \right)}}} + {i\; {{X\left( {t - \tau - \tau_{\alpha}} \right)} \cdot {X\left( {t - \tau_{\alpha}} \right)}}}} \right\rbrack}} & (5) \end{matrix}$

The real part from equation (5) is used as the stimulation stimulus:

real[S(t)]=K·[X(t)² ·X(t−τ)−X(t−τ _(α))·X(t−τ)+2X(t)·X(t−τ _(α))·X(t−τ−τ _(α))]  (6)

FIGS. 11A to 11C schematically show different possibilities for realizing a stimulation unit for generating vibration stimuli and/or tactile stimuli such as are shown in FIGS. 3A to 4. The stimulation units include a stimulation element 40, for example in the form of a bar, with whose one end the skin 15 of the patient is stimulated. The stimulation element 40 is driven by an electromechanical converter 41 (or actor or actuator) which converts electric energy into a movement of the stimulation element 40. DC motors, voice coils, piezoelectric converters or converters comprising electroactive polymers (EAPs) which change their form on application of an electric voltage are suitable as electromechanical converters 41.

The electromechanical converters 41 can be designed so that the stimulation element 40 is deflected perpendicular to the skin's surface (cf. FIG. 11A) or in parallel thereto (cf. FIG. 11B). The movement of the stimulation element 40 can, however, also take place on any other desired paths. A pendular deflection of the stimulation element 40 is shown as an example of this in FIG. 11C.

The end of the stimulation element 40 that comes into contact with the skin's surface and ultimately generates the stimuli can. for example, substantially have the shape of a hemisphere (cf. FIG. 12A) or can have a nub-like surface (cf. FIG. 12B) or can have another suitable shape.

An embodiment of a stimulation element for applying vibration stimuli and/or tactile stimuli is shown in FIGS. 13A to 13C in phantom view (cf. FIG. 13A), in plan view from below (cf. FIG. 13B) and in cross-section (cf. FIG. 13C). The present stimulation element includes a piezoactuator 41 as an electromechanical converter. Since the deflection of the piezoactuator 41 is not sufficient for the intended purposes, a mechanism can be provided for amplifying the deflection of the piezoactuator 41. A lever arm 42 is shown by way of example here which amplifies the movement of the piezoactuator 41. The lever arm is here an elongate flexible spring 42 whose one end is fastened to the housing 43 of the stimulation element and to whose other end the stimulation element 40 is attached. The piezoactuator 41 presses onto the upper side of the flexible spring 42 and the stimulation element 40 attached to the lower side of the flexible spring 42 follows the deflection of the piezoactuator 41 with an amplitude amplified due to the geometrical arrangement and applies the vibration stimuli and/or tactile stimuli to the skin of the patient. The lower side of the stimulation element 40 which comes into contact with the skin can have different geometries and dimensions. The stimulation element 40 can be flat, round or irregular at its lower side, for example.

Furthermore a space 44 for electronics and connection terminals can be provided in the housing 43 of the stimulation element which accommodates the piezoactuator 41 and the amplification mechanism. In addition, an adjustment ring 45 is attached to the lower side of the housing 43; it is connected to the housing 43 via a thread and allows an adjustment of the height by which the stimulation element 40 projects from the lower side of the stimulation unit in its position of rest. During operation, the lower side of the stimulation unit is seated on the skin of the patient and is fastened to the body of the patient by a suitable cuff, for example. In addition to or alternatively to the cuff, the stimulation unit could be fastened to the skin of the patient by a single-sided or double-sided medical adhesive tape. The housing 43 protects the patient from possible risks such as electric voltage.

FIG. 14A to 14B schematically show differently designed stimulation units for generating thermal stimuli such as are shown in FIGS. 5A to 5C. The stimulation unit shown in FIG. 14A works contactlessly and effects a heating of the skin by the light of an infrared LED 50.

Stimulation units which apply thermal stimuli by contact with the skin's surface are shown in FIGS. 14B and 14C. The stimulation unit shown in FIG. 14B includes substantially the same components as the stimulation unit from FIG. 11A with an electromechanical converter 41 and a bar-shaped stimulation element 40. The stimulation unit of FIG. 14B additionally has a heating element and/or cooling element (e.g. in the form of a heating loop) which heats or cools the stimulation element. The thermal stimuli are generated by the movements of the stimulation element 40 with which the stimulation element 40 repeatedly comes into contact with the skin 15 and is removed again. The temperature of the stimulation element 40 can be constant during the total stimulation.

Alternatively, the heatable or coolable stimulation element 40 can, as shown in FIG. 14C, be in contact with the skin 15 of the patient during the total stimulation period. The thermal stimuli are in this case generated by a time variation of the temperature of the stimulation element 40. An electromechanical converter is not necessarily required in this embodiment.

An embodiment of a stimulation element for applying thermal stimuli is shown in FIGS. 15A to 15C in phantom view (cf. FIG. 15A), in plan view from below (cf. FIG. 15B) and in cross-section (cf. FIG. 15C). The stimulation unit includes a bar-shaped stimulation element 40 whose lower end is heatable and/or coolable. The stimulation element 40 is driven by a cam disk 51 at its upper end. A DC motor 52 sets the cam disk 51 into rotation during the stimulation. The stimulation element 40 is deflected downwardly by the cams 53 attached to the lower side of the cam disk 51. A restoration spring 54 provides that the stimulation element 40 subsequently returns to its starting position. The rotational movement of the cam disk 51 is converted into a linear movement of the stimulation element 40 by this mechanism. As described above, the stimulation element 40 can either be in contact with the skin of the patient for a specific time or the stimulation element 40 is brought cyclically onto the skin by a rotation of the cam disk 51 and is removed again.

The components of the stimulation unit can be introduced into a housing 55. A space 56 for electronics and connection terminals can be provided in the housing 55. In addition, an adjustment ring 57 can be attached to the lower side of the housing 55; it is connected to the housing 55 via a thread and allows an adjustment of the height by which the stimulation element 40 projects from the lower side of the stimulation unit in its position of rest (the stimulation element 40 can also lie completely above the lower side of the adjustment ring in its position of rest due to the adjustment ring). During operation, the lower side of the stimulation unit is seated on the skin of the patient and is fastened to the body of the patient by a suitable cuff, for example. In addition to or alternatively to the cuff, the stimulation unit could be fastened to the skin of the patient by a single-sided or double-sided medical adhesive tape. The housing 55 protects the patient from possible risks such as electric voltage.

The stimulation units described in this application can be fastened individually to patients or several can also be integrated in one module. For example, a module can include a cuff with a plurality of stimulation units fastened thereto. The cuff can then be fastened to an arm or leg of the patient. FIG. 16 shows stimulation methods such as can be carried out using a total of N modules which each include four stimulation units, for example. In the stimulation method shown at the far left in FIG. 16, all the stimulation units apply a vibration stimuli 20, tactile stimuli 20 or they anal stimulus 20 at the start of a stimulation period T_(stim). In the stimulation method shown in the middle of FIG. 16, the stimuli 20 of the four different stimulation units of a module are each mutually displaced by T_(stim)/4. In this case, exactly one stimulation unit of each module applies a stimulus 20 in each time period of the length T_(stim)/4. In the stimulation method shown at the far right in FIG. 16, the four stimulation units of a module generate their stimuli 20 simultaneously, but the stimuli 20 of different modules are mutually displaced.

In all the stimulation methods shown in FIG. 16, any desired pauses can also be observed during the stimulation. Typically, the stimulation pauses have the length of one or more stimulation periods T_(stim). This is shown by way of example in FIG. 17. In the stimulation method shown there, a stimulation is carried out during two mutually following stimulation periods T_(stim); then a stimulation pause is observed during a stimulation period T_(stim). This pattern repeats periodically.

Further more, a randomization of the order in which the individual stimulation units generate stimuli can be added to the stimulation methods shown in FIGS. 16 and 17, with the following randomizations being conceivable among others:

1. Randomization of the stimulus sequences for each stimulation period T_(stim) coherently over all modules, i.e. at the start of each stimulation period T_(stim), an order is fixed in which the stimulation units generate the stimuli (e.g. the order Stim. #4, Stim. #2, Stim. #3, Stim. #1) and this order applies to all modules. 2. Randomization of the stimulus sequences for a block of mutually following stimulation periods T_(stim) coherently over all modules, i.e. at the start of e block of mutually following stimulation periods T_(stim) shown in FIG. 17 (or after a stimulation pause), an order is fixed in which the stimulation units generate the stimuli (e.g. the order Stim. #4, Slim. #2, Stim. #3, Stim. #1) and this order applies to all modules for the stimulation block up to the next pause. 3. Randomization of the stimulus sequences not varied coherently over all modules, but rather only coherently over a subgroup of all modules, i.e. a randomization in accordance with the above Items 1. or 2. is only carried out for a specific module (e.g. the module #2); the remaining modules behave as shown in FIG. 16. 4. Randomization of the stimulus sequences not varied coherently over all modules, but rather only coherently over a subgroup of all modules, i.e. a randomization in accordance with the above Items 1. or 2. is only carried out for two or more modules (e.g. the modules #2 and #4); the remaining modules behave as shown in FIG. 16. 5. Randomization of the stimulus sequences in uncorrelated form between different modules, i.e. an order in which the stimulation units generate the stimuli is fixed for each module independently of the other modules for each stimulation period T_(stim) or for each block of mutually following stimulation periods T_(stim) between two pauses.

The block diagram of an apparatus 300 for generating vibration stimuli and/or tactile stimuli and/or thermal stimuli is shown schematically in FIG. 18. The apparatus 300 includes n modules each having n stimulation units and n sensors. The modules and sensors are connected via connection lines or via radio (e.g. via a WPAN (wireless personal area network) network) to a connection module 60 which can in turn be connected to a computer 6L e.g. to a laptop, and to external apparatus 62. All modules and sensors do not necessarily have to be used simultaneously; depending on the type of stimulation, only a subset thereof can also be used. The modules and/or sensors can be supplied with power by batteries or rechargeable batteries so that they are independent of a central power supply. The user, for example a physician, can select a stimulation method by means of suitable software stored on the computer 61 and can set the parameters of this stimulation method.

The control of the stimulation units integrated in the modules can take place via the computer 61. As an alternative, a control unit 10 can be integrated in each module (cf. FIG. 19A) and is responsible for the control of the stimulation units of the respective module. This allows a largely independent operation of the modules. Furthermore, a separate control unit 10 can be provided for each stimulation unit (cf. FIG. 19B). This allows the greatest variety in the operation of the stimulation units, but the weight and the dimensions of the modules are hereby increased in size. As a further alternative, the control unit 10 can be positioned centrally in the connection module 60. The low weight and small size of the modules and an inexpensive manufacture are advantageous therein. However, in this embodiment, the modules cannot be operated independently of the connection module 60. 

1-21. (canceled)
 22. An apparatus for treating a patient using at least one of vibration stimuli, tactile stimuli, and thermal stimuli, comprising: N stimulation units configured to generate stimuli, wherein: the stimuli are at least one of vibration stimuli, tactile stimuli, and thermal stimuli, the stimulation units each generate the stimuli periodically at a frequency f_(stim) in a range of 1 to 60 Hz, the stimuli generated by different stimulation units are generated with a time offset, and the time offset between two mutually following stimuli amounts on average to 1/(f_(stim)×N).
 23. An apparatus in accordance with claim 22, wherein the stimulation units are skin stimulation units.
 24. An apparatus for treating a patient using at least one of vibration stimuli, tactile stimuli, and thermal stimuli, comprising: a first stimulation unit configured to administer first stimuli to the skin of a patient; and a second stimulation unit configured to administer second stimuli to the skin of the patient, wherein: the first and second stimuli are each at least one of vibration stimuli, tactile stimuli, and thermal stimuli, the first stimuli are forwarded, on a reception via receptors of the patient, to a first subpopulation of a population of neurons which have a pathologically synchronous and oscillatory activity, and the first stimuli have an effect that the phase of the neuronal activity of the first subpopulation is reset, the second stimuli are forwarded, on a reception via receptors of the patient, to a second subpopulation of the population of neurons which have the pathologically synchronous and oscillatory activity, and the second stimuli have an effect that the phase of the neuronal activity of the second subpopulation is reset, and the first and second stimuli are generated at least partly at different times.
 25. An apparatus in accordance with claim 24, wherein the first and second stimuli are each repeated on average at a frequency f_(stim) from 1 to 60 Hz during a stimulation period.
 26. A method of treating a patient using at least one of vibration stimuli, tactile stimuli, and thermal stimuli, the method comprising: administering first stimuli to the skin of a patient, wherein the first stimuli are received by receptors, the receptors forward the first stimuli to a first subpopulation of a population of neurons which have a pathologically synchronous and oscillatory activity, and the first stimuli have an effect that the phase of the neuronal activity of the first subpopulation is reset; and administering second stimuli to the skin of the patient, wherein the second stimuli are received by receptors, the receptors forward the second stimuli to a second subpopulation of a population of neurons which have the pathologically synchronous and oscillatory activity, and the second stimuli have an effect that the phase of the neuronal activity of the second subpopulation is reset, wherein the first and second stimuli are each at least one of vibration stimuli, tactile stimuli, and thermal stimuli, and wherein the first and second stimuli are generated at least partly at different times.
 27. A method in accordance with claim 26, wherein the first and second stimuli are each repeated at a frequency f_(stim) on average from 1 to 60 Hz during a stimulation period.
 28. A method in accordance with claim 26, wherein the vibration stimuli are periodic stimuli having a frequency in a range from 30 to 300 Hz.
 29. A method in accordance with claim 26, wherein a stimulation element vibrates at an amplitude up to 0.5 mm on a vibration stimulus.
 30. A method in accordance with claim 26, wherein a temperature in a range from 22° C. to 42° C. is generated on the surface of the patient's skin on a thermal stimulus. 